Happy Chilly Day, Everyone! (I was tempered in the Great White North, but burrrrrr!!) It ain’t the gorgeous sunny winter days of last week, but maybe chilly is conducive to sitting, typing in front of a space heater with a cat on my lap! Voila, February micro-CE…
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Lumps and bumps and bums. Don’t ask me how I group these things…my brain just goes here. More pocket-sized CE for your reading pleasure over that 2hr-lunch all of us veterinary types take! :\
I have been reflecting on some recent cases and discussions about patients with dermal/SQ masses and reading a quick little book called “Maximizing Biopsy Results” by F. Yvonne Schulman. I always like it when books pat me on the back and say, “Yep, that’s right.” (Sometimes you just have to acknowledge, to yourself, that you are excited that you know something!)
Anyhoo…back to bumps and biopsies. Why do them? Cytology got you something, right?…but read the last line of just about any aspirate cytology = equivocation. And no grade, no actual cell type. As the person looking to cure something (and make owners very happy), I like to speak as intelligently and efficiently as possible. An incisional biopsy allows me that efficiency. I don’t have to talk about a grade III, if it is a grade I. I don’t need to discuss the big C word if it is an organizing hematoma. My talking/typing goes way down when I have a “1.5cm, grade I hemangiopericytoma on the L lateral thigh of a Labrador” vs. “probable soft tissue sarcoma”. Fewer “If this…then this” comments.
How to do them? Well, ok, maybe backing up a bit…how to get the owners to allow you to do them? Is that a better question? Certainly not “needed”; we can lop anything off, right? But, if I charged by the pound of flesh removed, I could charge a lot less in the long run if I knew cell type and grade for “sure”. To cure with surgery, I need to get the right dose…appropriate margins. To get appropriate margins, I need to know cell type and grade. Am I being redundant?
Now, what if owners don’t want a cure “goal”, they “just want it off”? That’s fair. It’s a 15yr husky with an oozing, foul, ulcerated mass banging on the ground when she lies down. Totally fair. It’s a 2mm dermal nodule on the belly of a 50# beagle with tons of skin. Totally fair. Each patient and each mass and each owner-approach-to-life needs a customized plan. I’m just arguing that given the right information, more owners will elect incisional biopsies prior to mass resection because they buy into the logic and rationale for doing them. It’s a conversation with key points about why and what we gain. Key point—cell type and grade determine the size and morbidity of resection. (See attached owner handout that will help you reduce your talking time too!)
Now, how do you do an incisional biopsy (I’m talking lumps and bumps, not skin disease…)? Small but big enough. Don’t touch it. Avoid pus (or its cousins). Take more than one, let’s say…three…and don’t interfere with future oncological surgical margins! Respect the pathology professional veterinarian with an accurate case presentation.
Digging deeper on those snarky tid bits…
–If it is big enough to warrant an incisional biopsy, it can probably take a 6mm punch vs. 4mm punch. If you prefer scalpels and wedges, target 1cm as your goal.
–Put down your thumb forceps and use your suture as a tool. Take a bite of the mass with your suture. No need to tie, just cut 2-3cm tags. Hold those tags to lift and move your specimen. Get creative and use short vs. long tags to “label” each specimen (location or zone)
–An ulcerated zone of the mass has a bunch of PMNs obscuring the parent tissue that we want to know. Don’t sample there. Necrotic centers are dead zones. Don’t sample there.
–Take several samples from different zones of the parent mass, but (!) stay away from normal tissues lateral to and deep to the mass. Your surgical field will need to be removed with the mass (if cure is the goal) so don’t make it deeper or wider than the parent mass.
–Do unto others as you would have them do unto you. Communicate the case to your fellow professional. Signalment. Succinct clinical history leading to why you took the incisional biopsy. Lesion description; whip out your $20 words! Close your eyes and describe it with adjectives; paint a picture of the gross lesion for the person staring into the microscope. Differential diagnosis. Cytology results (even if they are “just” yours.) Your open questions.
Now, how do you get the patient to allow you to take an incisional biopsy? Trazadone and gabapentin are wonderful things. They open the door to easier approaches. Send home the oral meds with good timing instructions and proper expectations (so owner doesn’t think a stumbling dog is a bad thing). Restrain in a comfortable place with padding and not a lot of noise and activity. Utilize enough staff to allow you to focus on your field and immediate goal. Block the skin with sufficient local anesthetic (bupivacaine gives you and the patients a little more numb time; just don’t dive in too quickly) AND calculate your dose so you are not getting toxic in the tiny patients! (0.4cc/kg of the 0.5% bupivacaine) Top up wiggling patients with short acting IV meds (propofol or dexdom or butorphanol or midazolam) PRN.
Now, with that histo report, give me a jingle! We’ll talk tumors.
For some reason, I also have screwtail on the brain, so here’s the bum part as promised above…
Along with (IMHO) the life-changing nature of total ear canal ablation, I am going to enthusiastically add Screwtail Ablation to that short list! I have literally lost my hand in a full thickness rotten mess below a screwtail; I almost cried for that dog (after I took the clothes pin off my nose!) Can you imagine having to wipe and clean a deep ulcerated pocket on the bum end of your bulldog every day? Now imagine the poor dog when you actually don’t do that every day…oy! Enter the realm of the surgical cure to grumpy, sad, smelly, painful bum-itis.
The risk: benefit analysis is strongly in favor of benefit. Period.
Next time you are palpating per rectum for those anal sac masses you all are so wonderful at finding early, give a glance to the peri-tail region of the coccygeally-challenged breeds. If you can’t see all aspects of the skin because the pocket is too deep or collapsed, and you find moisture or odor or accumulated sloughed hair…and the dog says “KNOCK IT OFF!”…start the conversation. Anthropomorphize just a little with the owners to give them a little “taste” (bad word choice) of what their bully is experiencing at the tail end.
Give me jingle…I’ll gladly make that a happy bum for ya!
Nice talking with y’all. Keep on keeping on!
Lara
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